MKSAP Questions of the Week

General IM Q9

A 22-year-old man is evaluated during a pre-employment examination. The patient is starting a new job as a registered nurse. He is asymptomatic. He received the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine 7 years ago and the influenza vaccine during the last influenza season. Approximately 6 months ago, he received one dose of the measles, mumps, and rubella (MMR) vaccine because of lack of documented immunity on serologic testing. Medical history is negative for chronic medical conditions. He is a nonsmoker, and he does not plan to travel outside of the United States in the near future. He takes no medications. Physical examination is normal. Laboratory studies are significant for a positive result on a hepatitis B surface antibody test. Hepatitis B surface antigen, hepatitis B core antibody, and hepatitis A IgG antibody levels are undetectable.

Publish date: 10/13/2021

 
General IM Q8

A 68-year-old man is evaluated for fever, perineal pain, dysuria, frequency, and intermittent straining that began yesterday. Symptoms began 48 hours after a prostate biopsy due to an elevated prostate-specific antigen level detected during routine screening. On physical examination, temperature is 38.7 °C (101.7 °F), blood pressure is 145/82 mm Hg, pulse rate is 105/min, and respiration rate is normal. The prostate is enlarged and boggy, and it is tender to gentle palpation. There is no penile discharge, and no scrotal pain occurs with palpation. Dipstick urinalysis is positive for leukocyte esterase and nitrates. Urine Gram stain reveals gram-negative rods. Urine culture is pending.

Publish date: 10/07/2021

 
General IM Q6

A 52-year-old man is evaluated for a 2-day history of painless red eye, which began on the right side and quickly spread to the left. He reports that his eyes have a thin mucopurulent discharge and that his eyelids are matted shut in the morning upon waking. He has had no photophobia, change in visual acuity, or itching in the eyes, but he has experienced some mild rhinorrhea. He does not use contact lenses. He is sexually monogamous. Medical history is significant for type 2 diabetes mellitus treated with metformin. On physical examination, vital signs are normal. There is redness of the sclerae bilaterally, with a white crust-like residue along the edges of the eyelids. The tarsal vessels are obscured by the conjunctival erythema. Visual acuity is intact, and there is no tenderness around the globes.

Publish date: 10/01/2021

 
General IM Q5

A 23-year-old woman is evaluated for depression as she prepares for discharge from the hospital to home hospice care. She was diagnosed with metastatic ovarian cancer 2 years ago, and she progressed through four lines of chemotherapy, a trial of immunotherapy, and a failed attempt at a phase 1 clinical trial. Her life expectancy is measured in weeks. She is currently hospitalized with volume depletion, and after consultation with her oncologist and palliative care team, she has decided to be discharged home with hospice care. On physical examination, the patient exhibits substantial fatigue and poor concentration. She has a flat affect except when intermittently tearful. Previously upbeat despite all of the setbacks, she is now withdrawn and describes feeling hopeless. She has pervasive guilt over the burden she believes she has caused her family. Medications are a fentanyl patch, oxycodone, ondansetron, polyethylene glycol, senna, and zolpidem.

Publish date: 09/23/2021

 
General IM Q4

A 67-year-old man is evaluated for a 2-year history of worsening pain in his feet. He describes the pain as long-standing aching and burning. The pain is persistent, sometimes waking him from sleep. Medical history is otherwise significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Medications are insulin glargine, insulin aspart, valsartan, aspirin, and simvastatin. On physical examination, vital signs are normal. The feet are insensate to monofilament testing, and vibratory sensation is absent in the feet and ankles. No evidence of skin breakdown is noted

Publish date: 09/15/2021

 
General IM Q3

A 49-year-old man is scheduled for total right knee arthroplasty. Medical history is otherwise unremarkable. He takes no medications. On physical examination, vital signs are normal. The right knee demonstrates bony hypertrophy and crepitus with passive movement. Low-molecular-weight heparin and intermittent pneumatic compression will be initiated and continued during the hospital stay.

Publish date: 09/09/2021

 
General IM Q2

A 40-year-old woman seeks advice on whether she should undergo breast cancer screening with mammography. Her family history is negative for breast and ovarian cancers, and she has no other risk factors for breast cancer. On physical examination, vital signs and the remainder of the examination are normal. The patient is engaged in a discussion of the potential benefits and harms of initiating mammography now, including the potential for false-positive results and overdiagnosis. After the discussion, she states that she is not overly concerned about her risk for breast cancer but is anxious about the potential harms associated with screening.

Publish date: 09/01/2021

 
General IM 1

A 35-year-old woman is evaluated after laboratory test results showed an elevated LDL cholesterol level during routine screening. Family history is remarkable for myocardial infarction in her father at age 45 years. She takes no medications. On physical examination, vital signs are normal. BMI is 30. The remainder of the examination is unremarkable. The patient is instructed in therapeutic lifestyle changes to lower her risk for atherosclerotic cardiovascular disease (ASCVD)

Publish date: 08/25/2021

 
Rheumatology Q49

A 48-year-old woman is evaluated for a 2-month history of increased dyspnea, wheezing, and nonproductive cough. She also reports intermittent pain and swelling in the wrists and knees for the past 6 months. She was diagnosed with scleritis of the left eye 1 month ago that improved with glucocorticoid drops. She also had two episodes of right pinna pain, redness, and swelling. Medications are prednisolone acetate ophthalmic and ibuprofen as needed for joint pain. On physical examination, vital signs are normal. There is no rash. Sclerae are normal. Hearing is normal. The trachea is tender. On lung auscultation, wheezing is heard in both lung fields with no crackles or rubs. Swelling of the wrists and knees is present. The ear findings are shown. Laboratory studies show an erythrocyte sedimentation rate of 60 mm/h and a normal complete blood count with differential except for a hemoglobin level of 11 g/dL (110 g/L). Chest radiograph is normal. CT of the chest reveals bronchial thickening with strictures; there is air trapping distal to the strictures.

Publish date: 08/18/2021

 
Pulmonary and Critical Care Medicine Q54

A 38-year-old man is evaluated for a 6-month history of dyspnea on exertion. He has gastroesophageal reflux disease and Raynaud phenomenon. He does not smoke and has no cough or wheezing. Current medications are lansoprazole and amlodipine. On physical examination, vital signs are normal. Oxygen saturation is 91% breathing ambient air. He has scattered telangiectasias on the face and trunk and sclerodactyly. Lung fields are clear on auscultation. The only abnormality on pulmonary function testing is a DLCO of 43% of predicted. High-resolution CT of the chest shows no evidence of parenchymal lung disease.

Publish date: 08/11/2021

 
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